Epsdt Agreement Sample Contracts
EPSDT AGREEMENTEpsdt Agreement • September 29th, 2016
I, the undersigned participating physician/provider, agree to carry out the key components of a thorough medical well-child examination. The examination/screen must, at a minimum, include:
Select purpose of form below:Epsdt Agreement • May 16th, 2024
EPSDT AGREEMENT I, the undersigned participating physician/provider, agree to carry out the key components of a thorough medical well-child examination. The examination/screen must, at a minimum, include: ▪ a comprehensive health and developmental history (including assessment of both physical and mental health development), ▪ a comprehensive unclothed physical exam, ▪ appropriate immunizations according to age and health history, ▪ laboratory tests (including blood lead level assessment appropriate for age and risk factors), ▪ health education (including anticipatory guidance), and ▪ treatment and/or referral, if indicated. In addition, I understand that the performance of these services must be documented, as all medical records pertaining to the EPSDT Program are subject to audit by federal and state agency representatives. Also, I agree to follow up on all referred cases and to document whether or not the initial referral visit was kept by the recipient. Provider’s Printed Name P